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<title>Questionnaire No.3</title>
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<div align="center">
<form action="" method="post" enctype="multipart/form-data" name="questionnaire3_7" id="questionnaire3_7">
	<table border="0" width="800" id="table1" cellspacing="0" cellpadding="0">
		<tr>
			<td height="30">
			<p align="center">
			<font face="Verdana" style="font-size: 10pt; font-weight: 700" color="#000000">
			Questionnaire No. 3</font></td>
		</tr>
		<tr>
			<td height="19">
			<p align="center">
			<font face="Arial" style="font-size: 8.5pt" color="#000000">For 
			Field Survey (Village Level questionnaire) </font></td>
		</tr>
		<tr>
			<td height="18">
			<p align="center">
			<font style="font-size: 8.5pt" face="Arial" color="#000000">Page 8</font></td>
		</tr>
		<tr>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td bgcolor="#EEEEEE" height="20"><font color="#000000">&nbsp;
			<span style="font-weight: 700">
			<font face="Arial" style="font-size: 8.5pt">Risk Assessment &amp; 
			Analysis (For Each hand pump / Open well / Tube well / GLR / P &amp; T 
			systems) </font></span></font></td>
		</tr>
		<tr>
			<td>
			&nbsp;<font face="Verdana" style="font-size: 8.5pt" color="#000000">Source 
			of Information : 'O' = Direct Observation : 'I' = Interview</font></td>
		</tr>
		<tr>
			<td>
			<table border="0" width="100%" id="table12" cellpadding="0">
				<tr>
					<td width="58" align="center" height="29" bgcolor="#F7E6B7">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					S. No.</font></td>
					<td width="518" height="29" bgcolor="#F7E6B7">
					<p align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					Question</font></td>
					<td height="29" bgcolor="#F7E6B7">
					<p align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					Type</font></td>
					<td width="133" height="29" bgcolor="#F7E6B7">
					<p align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					Yes / No</font></td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					1</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is there a latrine within 10 meteres of the Handpump / Well</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q1[]" id="type_q1[]" value="O">O
				  		<input type="checkbox" name="type_q1[]" id="type_q1[]" value="I">I</font>                   </td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q1" id="risk_q1" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q1" id="risk_q1" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					2</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is there a Cattle water Trough (CWT) near the Handpump / 
					Well / GLR</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q2[]" id="type_q2[]" value="O">O
				  		<input type="checkbox" name="type_q2[]" id="type_q2[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q2" id="risk_q2" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q2" id="risk_q2" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					3</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Other than Latrines and Domestic animals, are there any 
					other sources of pollutions with ten meters of borehole? 
					(i.e. excreta, garbage, drains / channels, sewers, ponds, 
					dugwells, cultivation)</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q3[]" id="type_q3[]" value="O">O
				  		<input type="checkbox" name="type_q3[]" id="type_q3[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q3" id="risk_q3" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q3" id="risk_q3" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					4</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is there drain/ channel/ water logging / Pond nearby the GLR 
					/ Stand Post / P &amp; T</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q4[]" id="type_q4[]" value="O">O
				  		<input type="checkbox" name="type_q4[]" id="type_q4[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q4" id="risk_q4" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q4" id="risk_q4" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					5</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is the well parapet (wall) missing, damaged or less the 
					0.75m above the ground level.</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q5[]" id="type_q5[]" value="O">O
				  		<input type="checkbox" name="type_q5[]" id="type_q5[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q5" id="risk_q5" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q5" id="risk_q5" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					6</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Does the inner seal (i.e. lining) around the top of the well 
					extend less then 1.0 meter wide?&nbsp;&nbsp; </font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q6[]" id="type_q6[]" value="O">O
				  		<input type="checkbox" name="type_q6[]" id="type_q6[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q6" id="risk_q6" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q6" id="risk_q6" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					7</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is the Apron around the prapet&nbsp; missing, damaged, or 
					less then 1.0 meters wide.</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q7[]" id="type_q7[]" value="O">O
				  		<input type="checkbox" name="type_q7[]" id="type_q7[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q7" id="risk_q7" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q7" id="risk_q7" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					8</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is water withdrawn by rope and bucket, or windlass rather 
					then a pump?</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q8[]" id="type_q8[]" value="O">O
				  		<input type="checkbox" name="type_q8[]" id="type_q8[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q8" id="risk_q8" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q8" id="risk_q8" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					9</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is the discharge channel missing , damaged or blocked with 
					debris?</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q9[]" id="type_q9[]" value="O">O
				  		<input type="checkbox" name="type_q9[]" id="type_q9[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q9" id="risk_q9" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q9" id="risk_q9" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					10</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Can waste water or rain water collect within 3 meters of the 
					well/ or borewell ?</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q10[]" id="type_q10[]" value="O">O
				  		<input type="checkbox" name="type_q10[]" id="type_q10[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q10" id="risk_q10" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q10" id="risk_q10" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					11</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Can water, dirt or dust enter the well/borewell at the point 
					of attachment of handpump?</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q11[]" id="type_q11[]" value="O">O
				  		<input type="checkbox" name="type_q11[]" id="type_q11[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q11" id="risk_q11" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q11" id="risk_q11" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					12</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Is apron missing, damaged or less than 1.85 m in diameter ?</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q12[]" id="type_q12[]" value="O">O
				  		<input type="checkbox" name="type_q12[]" id="type_q12[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q12" id="risk_q12" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q12" id="risk_q12" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					13</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					can waste water collect on apron ?</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q13[]" id="type_q13[]" value="O">O
				  		<input type="checkbox" name="type_q13[]" id="type_q13[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q13" id="risk_q13" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q13" id="risk_q13" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					14</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Do people regularly bath, and wash closth or cooking/ eating 
					uthnsils at the hand pump/GLR</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q14[]" id="type_q14[]" value="O">O
				  		<input type="checkbox" name="type_q14[]" id="type_q14[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q14" id="risk_q14" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q14" id="risk_q14" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					15</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Are villagers satisfied with PHED supply </font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q15[]" id="type_q15[]" value="O">O
				  		<input type="checkbox" name="type_q15[]" id="type_q15[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q15" id="risk_q15" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q15" id="risk_q15" value="NO"> No</font></font>
					</td>
				</tr>
				<tr>
					<td width="58" align="center" bgcolor="#FDF9EE">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					16</font></td>
					<td width="518" bgcolor="#FDF9EE">
					<font face="Verdana" style="font-size: 8.5pt" color="#000000">
					Are there pvt TWs/OWs used by villagers for drinking water 
					supply</font></td>
					<td bgcolor="#FDF9EE" align="center">
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
						<input type="checkbox" name="type_q16[]" id="type_q16[]" value="O">O
				  		<input type="checkbox" name="type_q16[]" id="type_q16[]" value="I">I</font></td>
					<td width="133" bgcolor="#FDF9EE" align="center">
						<font style="font-size: 8.5pt" face="Arial" color="#000000">
						<input type="radio" name="risk_q16" id="risk_q16" value="YES">Yes
						<font style="font-size: 8.5pt">
				  		<input type="radio" name="risk_q16" id="risk_q16" value="NO">No</font></font>
					</td>
				</tr>
			</table>
			</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>&nbsp;
			</td>
		</tr>
		<tr>
			<td bgcolor="#EEEEEE" height="20">
			<font face="Arial" color="#000000">
			<span style="font-size: 8.5pt; font-weight: 700">&nbsp;
			<span style="font-weight: 700; font-size:8.5pt">
			<font style="font-size: 8.5pt; font-weight:700"></font></span>Result 
			and Recommendations </span></font></td>
		</tr>
		<tr>
			<td>
			<table border="0" width="100%" id="table13" cellspacing="0" height="74">
				<tr>
					<td bgcolor="#F7E6B7">&nbsp;<font style="font-size: 8.5pt" face="Verdana" color="#000000">&nbsp; 
					The following important points of risk were noted</font></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">
					<p align="center">
					<textarea rows="5" name="imp_points_risk" id="imp_points_risk" cols="125" style="font-size: 8pt; font-family: Verdana; border-style: solid; border-width: 1px"></textarea></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">&nbsp;</td>
				</tr>
				<tr>
					<td bgcolor="#F7E6B7">&nbsp;
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					N<font style="font-size: 8.5pt">ame of th</font>e Assessor
					</font></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">&nbsp;<input type="text" name="name_assessor" id="name_assessor" size="45" style="font-size: 8pt; font-family: Verdana"></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">&nbsp;</td>
				</tr>
				<tr>
					<td bgcolor="#F7E6B7">&nbsp;
					<font style="font-size: 8.5pt" face="Verdana" color="#000000">
					N<font style="font-size: 8.5pt">ame of th</font>e Key 
					Contact</font></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">&nbsp;<input type="text" name="name_key_contact" id="name_key_contact" size="45" style="font-size: 8pt; font-family: Verdana"></td>
				</tr>
				<tr>
					<td bgcolor="#F7E6B7">&nbsp;<font style="font-size: 8.5pt" face="Verdana" color="#000000"> 
					Contact Details&nbsp; </font></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">&nbsp;
					<textarea rows="5" name="contact_details" id="contact_details" cols="42" style="font-size: 8pt; font-family: Verdana; border-style: solid; border-width: 1px"></textarea></td>
				</tr>
				<tr>
					<td bgcolor="#FDF9EE">&nbsp;</td>
				</tr>
			</table>
			</td>
		</tr>
		<tr>
			<td>
			<table border="0" width="100%" id="table11" cellspacing="0" cellpadding="0">
				<tr>
					<td>&nbsp;</td>
				</tr>
			</table>
			</td>
		</tr>
		<tr>
			<td>&nbsp;
			</td>
		</tr>
		<tr>
			<td>
			<p align="center">
			<input type="submit" value="Submit" name="submit" style="font-size: 8pt; font-family: Verdana; border-style: solid; border-width: 1px"></td>
		</tr>
		<tr>
			<td>&nbsp;</td>
		</tr>
	</table>
	</form>
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